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Migraine in the Emergency Department: Not a Win-Win Situation
Blumenthal et al
Posted: February 2004  

Hypothetical scene from the popular television show "ER": Enter Dr. Carrie Weaver, a no- nonsense attending. "Who has the migraine in 6? Why is she still here? Get her out of here! We have to make room for 4 teens with multiple GSWs." And therein lies the crux of the problem: how to provide rescue care for migraine, an episodic condition which may be incapacitating but is rarely life-threatening.

The article by Blumenthal et al in a recent issue of Headache examines the emergency department (ED) experience for patients with primary headache as extracted from patient questionnaires correlated to ED records. The authors draw attention to various issues inherent to the ED headache encounter, many of which have been reported by others in recent years. These previous studies have been criticized due to methodologic concerns regarding ascertainmet of subjects, incomplete documentation in ED records, lack of standardized diagnostic criteria and lack of 24- or 48-hour follow-up data. While the percentage of responders to the questionnaires utilized by Blumenthal was low, this is typical of this type of study, and some familiar themes emerged. These include underdiagnosis of migraine as the specific primary headache type and underuse of “migraine-specific” medication.

Perhaps the striking result revealed by this study was the disconnect between the impression of the ED physician at the time of discharge and that of the patient 24 hours later. Although the ED notes indicated that a majority was improved at discharge, no patients were able to resume their routine activities immediately afterward and 60% reported persisting headache at 24 hours. A perceived response to treatment as judged by the ED physician typically did not equate to a robust or sustained response in the patient’s estimation. This article imprints in the medical literature what many of us have heard numerous times at office follow-up visits or at American Council for Headache Education (ACHE) support group meetings.

How can we improve rescue care for our patients? We can strive to improve the ED encounter, and we can try harder to keep our patients with migraine out the ED in the first place. The latter can be accomplished by providing backup medication options for patients at home and by developing alternative settings for acute care. Reduced use of the ED was also demonstrated through a disease management model of care for migraine at Kaiser Permanente in which the focus was on education and individualized care plans.